“Make thorough inspection.”
– Sir William Osler, MD.
The art of the physical exam is precisely that: an art that must be practiced often, for years on end, and the one that a physician may become a great achiever or skilled but never the master.
When I trained in internal medicine over a decade ago, our program director often harped on this art. I was too naive to understand his message at the time. But it became quite apparent after training when seeing or viewing others perform a subpar exam. Not in any way stating that I am an expert. However, part of prevention requires looking, hearing, and feeling- physically examining a patient. Most things will likely have gone unnoticed for far too long and likely have progressed pathologically. But not all. After all, there are numerous confounders, including patient and physician ones, disease course and aggressiveness.
Given today’s expectations and time constraints (as medicine is a business), it would be naive and unrealistic to suggest that every patient encounter requires a full physical exam. That’s what triaging is all about, right?
I have worn “Coke bottle” eyeglasses since elementary school. The ongoing family joke is that I have superhuman hearing and other senses to compensate for survival. My husband lovingly jokes that he wished I would always join his hunts as my sense of smell is beyond superb.
That being said, I have been privileged to find several cases of mild aortic stenosis and heart valve pathologies which necessitated further subspecialist monitoring and intervention. These examples are not in any way to give me a pat on the back but, instead, to highlight how important a physical exam is for comprehensive care. The best example I can think of involves a 48-year-old man who happened to end up on my clinic schedule due to his regular physician’s long wait time.
Being fairly new then, I had several openings for the same appointment slots. His chief complaint was nasal congestion for three days that was, above all, annoying. He had an important meeting and feared it would interfere with his presentation.
I have a minimum physical exam I perform out of a 10-year habit on every single encounter. He specifically commented when I adjusted my stethoscope in my ears, “Miss, I’m just here for my nose.”
And that’s when I heard it. A blowing, harsh systolic murmur radiated to his carotids. He had severe aortic stenosis and a valve replacement in the following weeks.
That was an exceptionally gratifying encounter. The cardiologist acknowledged how “astute” I was in his CC’d note. But I didn’t think so. I just performed an exam that I did approximately two dozen times a day. It saddens me to think others do not.
Part of the institution I worked for my first decade as an MD was also involved in academics. Because of this, I was involved in infrequent teaching. It was disheartening to see that most were not skilled at what I would consider basics, such as percussion, egophony, and having a patient perform different maneuvers to elicit changes in flow and, therefore, the sound of a murmur.
Sometimes, we need to step back and return to the basics. To find pathology, one must practice the art of the physical exam.
It seems fitting to end as I began with a quote from the father of internal medicine, Sir William Osler, “Methodical examination leads to safe induction.”
Brandi Fontenot is an internal medicine physician.
